Provider Demographics
NPI:1396444709
Name:MIKICIC, KIMBERLY KAY (OPTICIAN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:MIKICIC
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3657 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2924
Mailing Address - Country:US
Mailing Address - Phone:614-239-7829
Mailing Address - Fax:614-239-7834
Practice Address - Street 1:3657 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:OH
Practice Address - Zip Code:43213-2924
Practice Address - Country:US
Practice Address - Phone:614-239-7829
Practice Address - Fax:614-239-7834
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6688SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician